CE Update Note from the Editor-in-Chief Despite the best efforts of our Reviewers and Editorial staff, errors

can occur in articles published in LabMedicine that warrant more than just publication of an Erratum, including republishing an article with the errors corrected. The corrected CE Update below on a transfusion medicine-related topic is a case in point. Fortunately, these circumstances occur with rare frequency; however, when they do occur, the Editorial staff of LabMedicine review carefully the circumstances and act based on the best interests of the author, LabMedicine, and its readership. The right thing to do never requires any subterfuge, it is always simple and direct. ~Calvin Coolidge~
Submitted 6.4.10 | Revision Received 7.19.10 | Accepted 8.23.10

Update and Utilization of Component Therapy in Blood Transfusions

Stacy A. Gurevitz, MD (Department of Pathology, Baylor University Medical Center, Dallas, TX)
DOI: 10.1309/LMQHWOGYICR84M8Q

Abstract

Transfusion medicine has undergone diverse and fascinating advancements since its initiation in the early 20th century. One of these was the discovery that blood can be divided into individual components and delivered

separately. This is imperative in this field, where there is high demand but little supply. In this review, we strive to elucidate the most important elements of 4 commonly used components.

Keywords: component therapy, blood banking, transfusion medicine, packed RBCs, plasma, platelets, cryoprecipitate, ABO compatibility

After reading this article, readers should have improved understanding of new and updated concepts in blood component therapy, while continuing to understand the theories and history of this diverse treatment.

Hematology exam 51002 questions and corresponding answer form are located after this CE Update on page 241.

Today, blood transfusions nearly always consist of the administration of 1 or more components of blood. Whole blood transfusion is now limited to situations involving massive resuscitation (trauma). The most commonly used component is packed RBC, but several others, including platelets, plasma, and cryoprecipitate, are used as well. In this review, we will discuss the processing, uses, indications, contraindications, and other important features of blood components.

Corresponding Author
Stacy A. Gurevitz, MD StacyGurevitz@gmail.com

Abbreviations
pRBCs, packed red blood cells; TRAP, Trial to Reduce Alloimmunization to Platelets; DIC, disseminated intravascular coagulation; TTP, thrombotic thrombocytopenic purpura; vWF, von Willebrand factor; FFP, fresh-frozen plasma; TRALI, transfusion-related acute lung injury; AHF, antihemophilic factor; DDAVP, desmopressin

Packed RBCs Packed RBCs (pRBCs) are prepared from 1 unit of a whole blood donation by centrifugation. From 1 unit (450500 mL) of whole blood, 200 mL of RBCs are obtained (Figure 1). Various anticoagulant-preservative solutions (50 to 100 mL) are used to prolong the shelf-life of the cells. One solution is CPDA-1, which allows pRBCs to be stored for 35 days at 1-6C. ADSOL is another solution that extends the life of the unit to 42 days. During storage, RBCs age in processes similar to in vivo aging. Therefore, the spleen rapidly clears a portion of the cells on transfusion. Another process during storage is leakage of intracellular potassium into the unit. Although measured levels of potassium in 1 unit can be alarmingly high, hyperkalemia is rare following a pRBCs transfusion. Red blood cell transfusions must be serologically compatible (Table 1). The most important blood typing system involves the ABO antigens, present on all RBCs. As an infant, humans develop IgM antibodies to the antigens that they do not have. For example, a person with the blood type A has antiB antibodies, and vice versa. People with the blood type O contain no antigens, therefore they have anti-A and anti-B antibodies. These antibodies are in the recipients plasma and will attack donor RBCs if the antigen is presented. A recipient may receive RBCs with any antigen that they already have (because they do not have an antibody to it), so AB patients can receive type A, B, AB, or O blood.
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CE Update ABO incompatibility leads to complement activation against the donor RBCs, leading to intravascular hemolysis. This is extremely dangerous and can lead to mortality. Unfortunately, the most common cause of this situation is clerical error, such as misidentification of a patient.2 Another important blood group is the Rh system, named for the rhesus monkeys that aided in the discovery.3,4 The Rh system includes several antigens, but the terms Rh positive or negative refer only to the D antigen, also known as the Rh factor. About 80% of Caucasians are positive for the D antigen. Those who are not may have developed an anti-D antibody from previous exposure, most commonly via pregnancy or transfusion. Because anti-D antibodies are mostly IgG, which does not activate complement, a patient with anti-D antibodies who is given D positive (Rh positive) blood is likely to undergo extravascular hemolysis. It is important to avoid immunization of females to the D antigen by giving Rh-negative females only Rh-negative pRBCs because, unFigure 1_Blood Component Processing Summary. Whole blood is separated into pRBCs and platelet-rich plasma. The plasma component can be further separated into platelets and like the IgM antibodies found against platelet-poor plasma. Cryoprecipitate can be extracted from plasma via a slow thaw. the ABO antigens, IgG antibodies do cross the placenta. This can lead to a very harmful condition during pregnancy (even several years after immunization) called Table 1_Recipient Antibodies and Compatible Donor RBC Blood hemolytic disease of the newborn. Types Several other clinically significant antibodies IgM Antibody in pRBCs Donor Blood Type present in the recipients serum must be eluciRecipient Blood Type Recipient Plasma Compatible for Recipient dated by a test called the antibody screen. A positive antibody screen requires additional testing to O Anti-A, B O determine the identity of the antibodies present.5 A Anti-B O, A Indications for transfusion of pRBCs include B Anti-A O, B symptomatic anemia, which manifests as high AB None O, A, B, AB pulse rate, increased respiratory rate, dizziness, and weakness. While there is no standard hemoglobin or hematocrit used to define a need for transfusion, most institutions set one. A hemogloPlatelets bin of less than 7 g/dL or 8 g/dL are commonly used cutoffs. Packed RBC transfusions should not be used to treat nutriPlatelets are prepared by centrifugation of plasma and tional deficiencies or to expand blood volume.6 removal of the platelet-poor component.5 This process yields Several institutions are adopting measures to ensure a unit of approximately 50 mL and is termed random donor physicians are ordering pRBCs and other blood components platelets. Four to 6 of these units are nearly always pooled appropriately. One way of doing this is to encourage the prior to transfusion. Alternatively, in an apheresis process physician to determine and state the indication on the order called plateletpheresis, platelets are separated from whole form. An example of this form is seen in Figure 2. blood at the time of donation and the remainder of the blood One unit of pRBCs should increase the hemoglobin by is transfused back to the donor. The advantage of this process 1 g/dL to 1.5 g/dL and the hematocrit by 3%-5%.5 One unit is that it can yield a single donor platelet unit of 200-500 mL. should typically be transfused in less than 4 hours. As with One single donor unit must contain a minimum of 3.0 1011 all blood components, only normal saline should be adminisplatelets. It is possible to obtain 3 single donor units from tered in conjunction with pRBCs to protect the cells against 1 donor during 1 apheresis session.9 7,8 osmolarity disruption. Solutions with calcium (ie, lactated In the United States, plasma is retained in the unit for Ringers) should be avoided because the effectiveness of the pres-ervation; also, the anticoagulant used during the whole citrate anti-coagulant could be reduced in the presence of blood collection or apheresis procedure serves as preservation high levels of calcium. Medications should not be added and media.5,10 Platelets are stored at room temperature (20-24C) 9 a blood warming device should be used if necessary. with gentle agitation for 5 days. The purpose of the agitation 236
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Figure 2_Blood Transfusion Order Form. In order to increase the appropriate use of blood products, several institutions have adopted forms such as this one, used at Baylor University Medical Center in Dallas, TX. Physicians are encouraged to identify which of the indications has been identified in their patients. This form also allows for easier review of the reasons for transfusion in an institution.

is to prevent platelet packing and increase oxygenation of platelets, favoring aerobic metabolism.11 Platelets contain the ABO antigens; however, the concentration is only about 5% of that in RBCs. Recipient anti-A or anti-B antibodies may affect platelet survival, but should not cause a harmful reaction to the patient.12 It is acceptable practice to administer unmatched platelets.6 Rh is not expressed in platelets and therefore a mismatch should have no effect on platelet survival,12 but Rhnegative women of child-bearing age should receive only Rh-negative platelets to prevent isoimmunization because platelets do contain a small number of RBCs that can be Rh positive.6
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More clinically relevant are the HLA class-I antigens present on the WBCs in the platelet unit.13 Transfusion, especially with pooled-platelets (multiple donors), leads to alloimmunization to the HLA antigens. Future platelet (and other component) transfusions are subject to these antibodies, possibly deeming the patient refractory to platelet transfusion.14,15 The landmark Trial to Reduce Alloimmunization to Platelets (TRAP)16 study showed that leukocyte reduction is an extremely useful process to prevent alloimmunization by platelet transfusion. Also, single-donor platelets vastly decrease exposure to HLA antigens. Patients should obtain a rise of 20,000 to 40,000 platelets/uL following 1 unit, measured at 10 to 60 minutes following
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CE Update transfusion.9 It is important to consider variables Glossary of Terms when determining expected rise, including number of platelets transfused, recipient surface area, and CPDA-1: Citrate phosphate dextrose adenine, a preservative used the time interval between transfusion and measurein packed RBCs. ment.9,13,17 Refractoriness to platelets is defined as ADSOL: Adenine, dextrose, sorbitol, sodium chloride and mannitol; a a platelet count that is less than expected.13 There preservative used in packed RBCs. are several causes. Infections shorten platelet survival. Splenic uptake, bleeding, and disseminated Anemia: Reduced number of RBCs or hemoglobin in the blood stream. intravascular coagulation (DIC) can reduce platelet counts. Alloimmunization by HLA antigens (see Antigens: A molecule recognized by the immune system. above), ABO mismatch, and anti-platelet antibodies 17 are immunologic reasons for platelet destruction. HLA class-1: Human leukocyte antigen; the major histocompatibility complex Anti-platelet drugs already in the patients system in humans; present antigens to immune cells. can inactivate platelet function without reducing platelet number. Antibodies: Immune system protein that identifies and neutralizes foreign Bacterial contamination of blood products objects, such as viruses and bacteria. was responsible for 28 (13%) transfusion-associated fatalities in the fiscal years of 2005 through Immunization: Formation of antibodies against an antigen. 2008; of these, platelets (single-donor and pooled) were responsible for the majority (15 deaths).2 Complement: Biochemical cascade that aids the ability of antibodies to This is likely because platelets are stored at room destroy pathogens. temperature.18 Blood banks are required by the AABB, an international association of blood DIC: Disseminated intravascular coagulation; pathologic activation of the banking, to take preventative measures by detectcoagulation cascade in which small blood clots are formed in the small vessels ing bacterial contamination in platelet units.19 of the body; these clots consume coagulation proteins and platelets, leading The most frequently identified organisms are to abnormal bleeding. the gram-positive bacteria that contaminate the Hemolysis: Destruction of RBCs. skin (Staphylococcus sp.). For this reason, several strategies to clean the skin and divert the first part dDAVP: 1-desamino-8-D-arginine vasopressin; a synthetic replacement for of drawn blood (including the skin plug) are in the hormone vasopressin. place. Additionally, labs must screen platelets for contamination prior to transfusion. There are sevApheresis: Procedure in which blood drawn from a donor or patient is passed eral options for doing so, including glucose monithrough an apparatus separating the blood into constituents, some of which toring, pH testing, or culture-based systems. All, are returned back to the donor or patient. however, carry a risk of false-negative results. Indications for platelet transfusion vary by stability of patients. In stable patients, a count of less than 10,000/uL is an indication for transfusion. In febrile patients, a cutoff of 20,000/uL can be used. Bleeding patients or those undergoing surgery or be drawn from 1 patient into a double unit bag of about an invasive procedure can be transfused when their platelets 500 mL. If plasma is isolated from the unit of whole blood are less than 40,000-50,000/uL. Finally, a cutoff as high as and frozen within 8 hours from donation, the unit is termed 100,000/uL should be used when patients have an intracranial fresh-frozen plasma (FFP). If the plasma unit is frozen more bleed or bleeding of the retinal vessels.9 than 8 hours but less than 24 hours from donation, it is Platelet transfusion is an absolute contraindication in named FP24. FFP and FP24 can remain at -18C for up to thrombotic thrombocytopenic purpura (TTP), an autoim1 year. These units are thawed at 37C, and then they are mune microangiopathic hemolytic anemia. Patients have relabeled as thawed FFP or thawed FP24 and can be kept at inhibiting autoantibodies to the enzyme ADAMTS13, which refrigerated temperatures for 24 hours. After 24 hours, they are is responsible for the breakdown of von Willebrand facrenamed thawed plasma and can be stored for up to 5 days.9 20 tor (vWF). There are other causes, but the final common Recent studies have shown that thawed FP24 should be pathway is increased activation and aggregation of platelets, considered an acceptable alternative to thawed FFP.22,23 These leading to microthrombi in vessels. These microthrombi shear studies were warranted by the idea of restricting plasma dothe RBCs. Transfusion of platelets enhances the formation nors only to males due to the decreased chance of transfusionof microthrombi, drastically worsening the disease course.21 related acute lung injury (TRALI).24 Transfusion-related acute Alternatively, a plasma exchange transfusion should be started lung injury is caused by antibodies in the plasma against antias soon as possible. gens on recipient leukocytes.9,14,25 These antibodies are more likely in females because of past pregnancies. Either gender may obtain these antibodies during past blood transfusions. Although TRALI is much more common during plasma Plasma transfusions, it is possible during any blood component Plasma is the supernatant of centrifuged whole blood. It transfusion.14 is then drawn off into its own unit bag, which measures 250 Pretransfusion testing must include an ABO and Rh mL. Alternatively, apheresis technology allows for 2 units to type. Patients with type A, B, or O contain antibodies to the 238
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CE Update making a defective version of vWF or make too little of it. Von Willebrand factor normally forms Antigen on Plasma Donor Blood Type bridges between platelets and endothelial cells, Recipient Blood Type Recipient RBCs Compatible For Recipient an essential part of primary hemostasis. Another important role of vWF is as a carrier protein for O None O, A, B, AB factor VIII. Factor VIII has an extremely short A A A, AB half-life when not bound to vWF. Discovered in B B B, AB 1977, desmopressin (dDAVP), a synthetic analog AB A, B AB of antidiuretic hormone, increases circulating factor VIII and vWF by promoting release of vWF from endothelial cells.29 While this treatment is very effective in patients with a quantitative antigens that they do not have. Patients with blood type AB deficiency in vWF (Type I vWD), it is essentially ineffecdo not contain these antibodies (Table 2). An antibody screen tive in patients with a qualitative defect in or virtually absent is usually performed at the donor center, and plasma with numbers of vWF (Types II and III, respectively).30 Additionknown antibodies are labeled as such and possibly withheld ally, patients with Type I vWD can be refractory to dDAVP. from distribution. AB plasma is the universal donor plasma While cryoprecipitate can be used to treat these patients, it and may be transfused to patients of any blood type. is no longer the standard of care. Factor VIII concentrates Plasma transfusion is indicated in settings where the that contain vWF are safer and more efficacious alternapatient is known to have multiple clotting factor deficiencies tives.6,31,32,33,34 with active bleeding, such as liver disease and warfarin therapy, Currently, cryo is used mainly as a replacement for fiand not to supplement a known deficiency of 1 clotting factor brinogen.5 This is required in several situations, including if there is a factor concentrate available. Factor concentrates liver failure, DIC, or massive transfusions. However, in these are safer.9 In treatment of TTP, an exchange transfusion situations it is important to examine patients for deficiencies removes the patients autoantibody by removing plasma. in other clotting factors, in which case FFP would be preDonor plasma, containing valuable vWF protease activity, ferred. Cryo can be used when uremic patients are bleeding is transfused simultaneously.26,27 This sometimes emergent and when there are rare congenital deficiencies in fibrinogen. procedure can be lifesaving. Plasma transfusion should not be used as a volume-expander or in the setting of nutritional deficiency without factor deficiencies.9 Summary Component therapy is a fascinating use of a limited resource. Innovative discoveries regarding patient disease and Cryoprecipitate technological advances to blood preservation and storage Cryoprecipitated antihemophilic factor, known as cryocontinue to expand this field of medicine, and therefore it is precipitate or cryo, is extracted from frozen plasma (FFP or imperative to understand the basis of each component. LM FP24) by slowly thawing a unit at 1C-6C.5 (When being prepared for transfusion, FFP or FP24 are thawed more rap 1. Steensma DP, Pruthi RK. Hematology. In: Ghosh AK. Mayo Clinic Internal idly at 37C.) This process produces a slushy-like substance, Medicine Review. Rochester, MN: Scientific Publications; 2008:427. which is centrifuged to separate the insoluble component. 2. U.S. Food and Drug Administration. Fatalities reported to FDA following blood Once removed, the cryo unit must be refrozen within 1 hour collection and transfusion: Annual summary for fiscal year 2007. Available at: and expires 1 year later. www.fda.gov. Accessed May 25, 2009. One unit of cryo is 15 mL. Cryo contains at least 150 3. Landsteiner K, Wiener AS. An agglutinable factor in human blood recognized by immune sera for rhesus blood. Proc Soc Exp Biol Med. 1940;43:223-224. mg of fibrinogen and at least 80 IU of factor VIII. These represent 20%-40% of the fibrinogen and 50% of the factor 4. Landsteiner K, Wiener AS. Studies on an agglutinogen (Rh) in human blood reacting with anti-rhesus sera and with human isoantibodies. J Exp Med. VIII of the original unit of plasma. Von Willebrand factor is 1941;74:309-320. 9 another important component of cryo. 5. Hughes VC, Wright PA. Donor Screening and Component Preparation. In: ABO compatibility is suggested, but not required for cryo Harmening DM. Modern Blood Banking and Transfusion Practice. Philadelphia, transfusion.6 One unit of cryo should lead to a rise in the rePA: FA Davis Company; 2005. cipients fibrinogen by 5-10 mg/dL.5 Often 8-10 units of cryo 6. Practice guidelines for blood transfusions: A compilation from recent peer-reviewed literature. American Red Cross; 2007. are pooled. 7. Standards for blood banks and transfusion services. Bethesda, MD: American Historically, Dr. Judith Graham Pools discovery in 1965 Association of Blood Banks; 2006. that cryo is rich in factor VIII and can be transfused28 led to 8. Circular of Information for the Use of Human Blood and Blood Components. a major advancement in the treatment of hemophilia A. Only Bethesda, MD: AABB; 2009. small volumes of cryo are needed, eliminating the volume-over 9. Davenport RD, Mintz PD. Transfusion medicine. In: McPherson R, Pincus M. loading that came with transfusion of plasma units. AdditionHenrys Clinical Diagnosis and Management by Laboratory Methods. Philadelphia, ally, since the product could be stored in blood banks, patients PA: Saunders Elsevier; 2006. with hemophilia A were granted access to elective surgeries and 10. Harmening DM, Moroff G. Red cell and platelet preservation: Historical perspectives, review of metabolism, and current trends. In: Harmening DM. underwent much safer emergent surgeries. In the 1970s, factor Modern Blood Banking and Transfusion Practices. Philadelphia, PA: FA Davis concentrates became available, and now cryo should be used to Company; 2005. treat hemophilia A only when these are not accessible.6 11. Vassallo RR, Wagner SJ, Einarson M, et al. Maintenance of in vitro properties of Von Willebrand disease, like hemophilia A, is an inherleukoreduced whole blood-derived pooled platelets after a 24-hour interruption of agitation. Transfusion. 2009;49:2131-2135. ited bleeding disorder. Patients with the disease have mutations
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12. Murphy MF. ABO and RhD compatibility in relation to platelet transfusions. Publication of the National Blood Service Transfusion Medicine Clinical Policies Group. 2000. 13. Rebulla P. A mini-review on platelet refractoriness. Haematologica. 2005;90:247253. 14. Cook LO, Wise SC, Larison PJ. Adverse effects of blood transfusion. In: Harmening DM. Modern Blood Banking and Transfusion Practice. Philadelphia, PA: FA Davis Company; 2005. 15. Heal JM, Blumberg N, Masel D. An evaluation of crossmatching, HLA, and ABO matching for platelet transfusions to refractory patients. Blood. 1987;70:23-30. 16. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. The Trial to Reduce Alloimmunization to Platelets Study Group. N Engl J Med. 1997;337:1861-1869. 17. Hod E, Schwartz J. Platelet transfusion refractoriness. Br J Haematol. 2008;142:348-360. 18. Murphy S. Platelet storage for transfusion. Semin Hematol. 1985;22;165-177. 19. Murphy S, Sayar SN, Gardner FH. Storage of platelet concentrates at 22C. Blood. 1970;35:549-557. 20. Fatal Bacterial Infections Associated with Platelet TransfusionsUnited States, 2004. JAMA. 2005;293:2586-2591. 21. Red Blood Cell and Bleeding Disorders. In: Kumar V, Abbas A, Fausto N, et al. Robbins and Cotran Pathologic Basis of Disease. Philadelphia, PA: Saunders Elsevier; 2010. 22. Harkness DR, Byrnes JJ, Lian EC, et al. Hazard of platelet transfusion in thrombotic thrombocytopenic purpura. JAMA. 1981;246:1931-1933. 23. Scott E, Puca K, Heraly J, et al. Evaluation and comparison of coagulation factor activity in fresh-frozen plasma and 24-hour plasma at thaw and after 120 hours of 1 to 6 degree C storage. Transfusion. 2009;49:1584-1591. 24. Naghadeh HT, Roudkenar MH. A study of the quantity of some stable and labile coagulation factors in fresh-frozen plasma produced from whole blood stored for 24 hours in Iran. Blood Transfus. 2009;7:39-42. 25. Eder AF, Herron R, Strupp A, et al. Transfusion-related acute lung injury surveillance (2003-2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross. Transfusion. 2007;47:599-607. 26. Kleinman S, Gajic O, Nunes E, et al. Promoting recognition and prevention of transfusion-related acute lung injury. Crit Care Nurse. 2007;27:49-53. 27. Sadler JE, Moake JL, Miyata T, et al. Recent advances in thrombotic thrombocytopenic purpura. Hematology Am Soc Hematol Educ Program. 2004:407-423. 28. Zheng XL, Kaufman RM, Goodnough LT, et al. Effect of plasma exchange on plasma ADAMTS13 metalloprotease activity, inhibitor level, and clinical outcome in patients with idiopathic and nonidiopathic thrombotic thrombocytopenic purpura. Blood. 2004;103:4043-4049. 29. History of Bleeding Disorders. National Hemophilia Foundation. Available at: www.hemophilia.org. Accessed May 25, 2009. 30. Mannucci PM, Ruggeri ZM, Pareti FI, et al. 1-Deamino-8-d-arginine vasopressin: A new pharmacological approach to the management of haemophilia and von Willebrands diseases. Lancet. 1977;1:869-872. 31. Mannucci, PM. Treatment of von Willebrand disease. Haemophilia. 1998;4:661. 32. Mannucci PM, Chediak J, Hanna W, et al. Treatment of von Willebrand disease with a high-purity factor VIII/von Willebrand factor concentrate: A prospective, multicenter study. Blood. 2002;99:450-456. 33. Lillicrap D, Poon MC, Walker I, et al. Efficacy and safety of the factor VIII/von Willebrand factor concentrate, haemate-P/humate-P: Ristocetin cofactor unit dosing in patients with von Willebrand disease. Thromb Haemost. 2002;87:224260. 34. Rivard GE, Aledort L. Efficacy of factor VIII/von Willebrand factor concentrate Alphanate in preventing excessive bleeding during surgery in subjects with von Willebrand disease. Haemophilia. 2008;14:271-275.

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